00010086APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY(
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING, PROJECT IDEM'IFICATION
ERMIT NO.
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMHTALDATE
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BUILDING PERMIT INFO
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❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB ME
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LICENSEUCONTRACIOR'S DIfCLARNTION
I hereby arum that I am license under Provisions of chapter 9 (commencing
IhSalion TlXXq ofDivisimn}nf the Business and Pr Codeendmylieensei%
W1 y
mfullfmceaodellcm ✓ sty s
Liccase 'a' //- er ',T
um Contractor
Oily ELECTRIC PERMIT FEE
JOB DESCRIPTION
RR SIDS
❑SFDWh ❑ KITCHEN REMODEL
❑ADDITION - ElPLUMBING RE-PIPE
❑MULTI-UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMINGPOOIS
❑ PATH REMODFL/REPAIR DIiM01.11'[ON
❑OTHER
PEHMITISSUANCE
APPLIANCES-RESIDENTIAL
ARCHITI2CTS DFCLA AVON
I understand myplan% shall beu.elas publierecnNs
MANIAS
UP TO 29)AMPS
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Licensed Pr afe...... a1
I hereby alErm thWN amlexdmpt frnLDER lm the Commmor's Licemc law ins the ATION
Infusing reason.(Seelion 903 L5. Business and professions Cole: Any city 0, county
which requires a pVmil ,, constmal, alter, improve, demolish, or repair any atmcture
prim it) its issuance. also requires the applicant for such permit o file a signed statement
m
that he is licensed pursuant to the provisions of the Cnrocon'l License law (Chagcr 9
(.ommmncing with Section 7001 of l)ivisian 3aftha Business and Profession, Code)m
That be is exempt damdoxm and the basis for the alleged evenmptiun. Any violation of
y any app ) penalty
Section 903156 applicant for a permit subjects the applicant to a ci vil h f
a more than Five, hundred dehats ($510).
DI, us nwnen+(0a pe,+pcny,nrmycmpinyeexwilhwagcs usthcirsulennn 1
will dothewark,and thenmcmre i—ol immrdeJoroRerNPormle(Sec.](
and Profession% Code: The Contractor's Licensed Law does not apply nm a % roof
poxpeny who builds m improves thereon, and who dons such work haa,el woe
his own employees, provide that such impmvemems are nut amended o Bee lir
%iris If, however, the holding or improvement is sold within one year ofa Iction, the
201-10MAMPS
OVER IgN1AMP5
SIGNS ELECTRICAL
SP17CIAL Cl RCUIT/MISC.
DIM P. MET I? R OR POLE INS'(
COMMERCIAL:
❑NEW NLIIG/ADDITION EMOLITION
❑TENANT ❑FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING 11001. LLECfRic
'fl. TIP FIXTURES
NEW SIDE' I EI I'
I
$Q, FT FLOOR AREA
ESQ.tT.
crhaider will have the f o den al .win, that he did not build or Ito Lou r
pose of salief
I, as owner of The pn+peny, am exclusively contracting with licensed centimeters to
L
rtm'nw Ihu p...No (Sec 9044, lion and Prole,,rax Cnde:) The Con.mmer'x Li-
ccuse Law d«s not apply to an owner of pmpcdy who build, or improve thereon, and
QTY. PLUMAGI Prom E
who mmracrc far such packets with a commemr(s) licensed pursuant the Cmumahm's
PERMIT ISSUANCE
Lar"", Law.
I ora exempt under Sec. , B & P C for this rcallm
ALTER-DRAIN & VENT-NATER (PA)
Owner Doe
VALUATION
WORKERS COMPENSATION DECLARM
RACK FLOW PR(YI'ECT. DEVICE
ial
1 hereby affirm under penalty of perjury tine of the follmving dcdarationr.
STORMS
"TYPE CONSTRUCTION
I have and will maintain a Cenillame of Consenno self- insure for Worker's Countries-
%Minn, us provided for by Scction 7910 of Inc Lobar Cede, for the pcifnnnome of the
work for which this Permit is issued.
DRAINS- FLOOR, ROOF, AREA. GOND.
FIXTURES - PER TRAP
1 have and will maintain Worker`s Compensation Insurance, as required by Section
3700al he My WnrAc Lahti+ + the !irinjuve of the vaulk far which this is issued,
j5f �n 'nn In rdPolicy numMr
Conic nw - 0
(ICC GROUP
APN
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" 1
40UTLEIS
GAS-EA. SYSTEM-i INC.OVER
GAS- EA.SYSTEMOVER4(GA)
GRFASE/INDUSI'RI. WAS 1'17 INTERCEPTOR
("I:RIIM11 A llr IONYI ROM W(IRKERSpunnit
COMYIiNSA'1'ION INSURANCE
BUILDING DIVISION FEES
flhis section need not be completed!ifthe permit is forone hundred dollars (SIM)
m Ices.)
GREASETRAP
PhANCHECK PEE
SEWER-SANITARY-STORM EA. 200 FI.
ENERGY FEE
I ttnif,und in the perfermance of the work fur which this pared is issued.I shall
not employ any person in any manner so as to become subject to the Workers' Compcn-
WATER HEATER W/VENT/ELEC R
GRADING ME
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.'alio. Luwv of California, Ilam
NOTICE TO APPLICA VI: If, after making this Ce ifnm of Exemption. You should
beconm %object to the Worker's Compensation provisions of the Labor Cade. You must
I'onhwllh,angmly with ouch previsions or Ibis penial shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihcrchy nl'lirm lbrn those ixn u+mlmcrimn lending agency far abed lnrformunm of
the work far which this permit is issued (Sec. 3097, Civ. C)
Lender', Name
WATER SYSTEMORiiATING
WATER SERVICE
SOILS FEE
PAID
Dem R<miptX
NEW RESIDENTIAL. PLMB. $Q. FI'.
TOTAL:
TOTAL:
Leadcr'x Address
BUILDING PEE
i
1 celiac (hal 1 have real this application and %tins that the above ws rmaang n
rorzcn.l agrecmcomply hcoehy cimyznd county ordinances coolantr.,,Ithe
M1uilding con%Imetinn, unit hereby umhoriec repreacnmtivn of this city nm emerupnm the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
SEISMIC
PIiRMITISSUANCE
ELECTRIC FEE
above-mentioned pmpemy for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupcnino against
PLUMBING FEE
Iiabi litu%,judgments, casts and expanses which may in any way nacre against said City
ce of the gaining of this 'il.
ICIER OR ADD "FO MECII.
AIR HANDLING INET (TO IO.IXO CPM)
MECHANICAL PEE
AcPLICAN
APPLICANT UNDER STA ' SAND 'ILL CO PLY W H AL1, NONPOINT
D
SOURCE RLGULAT
AIR HANDLING UNIT (OVER IU.INNI CFM)
CONSTRUCTION I'A%
2 / O
,ig awrc Appli nUsConalctur Date
I t A/',ARDOUS MAL FRIALS DISCLOSURE
EXHAUST HOOD(WNUCIl
HOUSING MITIGATION PEE
I (EATING UNIT (r0 1 W,dfo BTU)
Will the applicant lir fumru Iwilding+ncupunl nnrcar handle hawNow omeriol
as defined by the Cupoaino Municipal Cee. Chapter 9.12, and me Health ate Safety
Ce, Scction 25532(x)'! aaa'''''''''
/ ❑Yes DWLm
BEATING UNIT (OVER 100, 00 BTU)
PAID
Dated Receipm X
VIiNTILAI'ION PAN (SINGLE RESID)
V
Will the applicant or future holding uocupa.t use e,mMnem lir devices which
mit hamNuus air contuminuns radcGned by the Buy Area An Quality Management
BOILER-COMP(111P OR 1010,000BTU)
I QI'AL.
BOILER - COMP (OVER 100,11(0 BTU)
r°tact^
Al It CON DI i' ION ER
I have reed the haearadous matenals a under Chapter 6.95 o1' the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
5.2553an
fomia Health & Safay Code. Section%255(15. 25533 and 255N. I understand that if the
buildingJmnxnm,u Yb' tcnan4t tit it lxrrrym-pnrrsib'ity to nolilythelacupunt
n+rtoi. .eu C
�he squire � hT a he n cnif�yt����nc
ISSUED BY
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ih n .cJ agcntn .cJ ager��am
OFFICE